Valuation of Defined Benefit Pension Plan

Name:

Firm:

Street Address:

City:

State:

ZIP:

Phone:

FAX:

Email Address:

Pensioner Name:

Gender:
Male Female

Date of Birth:

Employer:

Name of Plan:

Date entered Plan:

Is the Pensioner still employed?
Yes No

If no, date of termination:

Spouse's Name:

Date of Birth:

Date of Marriage:

Valuation Date:

(Date of separation, filing, dissolution or trial, as appropriate in your state)

How much will the monthly
Pension Payment be?

When will
they begin?

Please Describe any Survivors Benefits:

Please send us a copy of the summary plan booklet
and the most recent benefit statement.

Please list the gross base pay for the current year and each of the previous three years.

Current Year:

In addition to the present value of the pension,
do you wish us to show the marital
interest based on the ratio of service during
the marriage to the total plan service.
(Also known as the "Time Rule" or "Coverture Percentage")?
Yes No

Do you need this valuation "Tax Impacted"?
(If "YES", please send us a copy of the prior year tax return)
Yes No

If "YES", please describe below:

Payment Information

Please submit a check for $150 payable to CDLM CPA's, LLP to:

CDLM & Company CPA's, LLP
Attn: John E. Little, CPA
401 East State Street, Suite 500
Ithaca, New York 14850

We make no attempt to independently verify your data.
The accuracy of our report depends upon the validity and completeness of the
data submitted with this form.